DOVER — Delaware has set a goal to become one of the nation’s five healthiest states by 2020 and an integral part of that goal is an initiative called Healthy Neighborhoods.

By 2018, Delawareans will be more engaged in their health care and have more positive health outcomes through a program called Healthy Neighborhoods.

Just a few years ago, the state was strategizing ways to make Delaware a healthier state and how to improve the number of positive patient outcomes, because despite spending an average of 25 percent more per capita on health care than the U.S. average, outcomes remain average or below in many areas.

While brainstorming on how to improve, The Center for Medicare & Medicaid Innovation was offering federal grants to states working on improvements to health and health care within their state.

A grant application was formulated by the Health Care Commission and Delaware was awarded a planning grant to develop a formal plan for implementing changes.

“Other states have tried strategies like ours before with varying degrees of success but our plan is more innovative and focuses on many aspects of health, not one specific thing like obesity,” said Matt Swanson, co-chair of the Healthy Neighborhoods committee. “The idea was to use our plan to get another grant to implement it. I think our approach is what set us apart.”

Last fall the state applied for a $40 million grant to follow through with its plans and was awarded $38 million. Although Healthy Neighborhoods is only one aspect of the overall plan which includes payment reform, practice transformation and more, Mr. Swanson said it’s an integral piece of the puzzle.

“The program will bring communities around certain health initiatives and priorities,” Mr. Swanson said. “We are working to connect care providers with the formal health care system and to have residents more engaged in their own care so everyone gets the positive outcomes they deserve.”

Healthy Neighborhoods will break down the state into a dozen “neighborhoods” where care will be coordinated between doctors, businesses and various non-profits.

“These aren’t just going to be pockets here and there, they’re going to cover the whole state,” Mr. Swanson said.

He used an example of a hip replacement to explain how Healthy Neighborhoods will help patients.

“After the surgery is over, there is still a lot of work the patient has to do to achieve a successful outcome that the doctor has no control over,” he said. “But the patient may have access to the YMCA for rehabilitation services, transportation to get to the Y or follow-up appointments. Now these are things patients may not know are available, but the goal of Healthy Neighborhoods is to coordinate these services so more patients see positive outcomes.”

Healthy Neighborhoods will also work alongside the Department of Public Health (DPH) to promote community health services, initiatives and programs throughout the state like the Worksite Wellness Program, Healthy Weight Collaborative and Promoting Healthy Activities Together.

Those responsible for the coordination are doctors who can guide patients to the services available to them and community leaders, including those involved in relevant businesses and non-profits.

“We aren’t asking for a huge time commitment from anyone,” Mr. Swanson said. “Every neighborhood will have a self-forming council to head this up and no two neighborhoods will have the same type of council. It will really depend on the community leaders and the local organizations involved.”

Each neighborhood will have its own council because local leaders have better knowledge of the community’s needs and workings than a statewide council does. The program is not a one-size-fits-all operation.

But the weight of organizing the program doesn’t rest solely on volunteers within the community. The Delaware Center for Health Innovation (DCHI), responsible for executing and overseeing Healthy Neighborhoods will have eight full-time employees working on the program.

The DCHI will lead the formation of each council by determining community leaders of various roles and relevant non-profits. Each new council will be coached on how to promote the framework and make Healthy Neighborhoods a successful program in their area.

“This is a practical idea and I think we will see success because with the planning grant, we were given the time and resources to be thoughtful about the program and really develop all the fundamental ideas to lay this framework,” Mr. Swanson said.

The cost of implementation and the extra DCHI employees is covered in the federal grant the state was awarded last fall.

“If there wasn’t any formal organization coming from the state level, this is something that could stagnate quickly but with DCHI involved, we can make sure this is a program that keeps moving forward,” Mr. Swanson said.

By the end of the year, Mr. Swanson estimates Healthy Neighborhoods will be implemented in one or two pilot neighborhoods before expanding the model across the state.

By the end of 2016, 10 percent of Delaware will be covered by Healthy Neighborhoods, followed by 40 percent by the end of 2017 and 80 percent by the end of 2018.